EXERCISE HISTORY & ATTITUDE QUESTIONNAIRE

EXERCISE HISTORY & ATTITUDE QUESTIONNAIREName:Date:General Instructions: Please fill out this form as completely as possible. If you have any questions, DO NOTGUESS; ask your trainer for assistance.1. Please rate your exercise level on a scale of 1 to 5 (5 indicating very strenuous) for each age range through yourpresent age:15-20 21-30 31-40 41-50 51+2. Were you a high school and/or college athlete?Yes No If yes, please specify:3. Do you have any negative feelings toward, or have you had any bad experiences with, physical activityprograms?Yes No If yes, please explain:4. Do you have any negative feelings toward, or have you had any bad experiences with, fitness testing andevaluation?Yes No If yes, please explain:5. Rate yourself on a scale of 1 to 5 (1 indicating the lowest value and 5 the highest value).Mark the number that best applies.Characterize your present athletic ability.1 2 3 4 5When you exercise, how important is competition?1 2 3 4 5Characterize your present cardiovascular capacity.1 2 3 4 5Characterize your present muscular capacity.1 2 3 4 5Characterize your present flexibility capacity.1 2 3 4 56. Do you start exercise programs but then find yourself unable to stick with them?Yes No7. How much time are you willing to devote to an exercise program?minutes/daydays/week8. Are you currently involved in regular endurance (cardiovascular) exercise?Yes No If yes, please specify:Type(s): minutes/day days/weekRate your perception of the exertion of your current exercise program.Mark the number that best applies.Light Fairly Light Somewhat Hard Hard

EXERCISE HISTORY & ATTITUDE QUESTIONNAIREPage 29. How long have you been exercising regularly?monthsyears10. What other exercise, sport, or recreational activities have you participated in?In the past 6 months?In the past 5 years?11. Can you exercise during your work day?Yes No12. Would an exercise program interfere with your job?Yes No13. Would an exercise program benefit your job?Yes No14. What types of exercise interest you?Walking Jogging Other AerobicCycling Traditional Aerobics Strength TrainingStationary Biking Elliptical Striding Racquet SportsStair Climbing Swimming Yoga/Pilates15. Rank your goals in undertaking exercise:What do you want exercise to do for you?Use the following scale to rate each goal separately:Not Important Somewhat Important Extremely Important1 2 3 4 5 6 7 8 9 10a. Improve cardiovascular fitnessb. Body-fat weight lossc. Reshape or tone my bodyd. Improve performance for a specific sport or activitye. Improve moods and ability to cope with stressf. Improve flexibilityg. Increase strengthh. Increase energy leveli. Feel betterj. Enjoymentk. Other16. By how much would you like to change your current weight?(+) pounds (-) poundsSignature:Date:Fitness Trainer (please print):Fitness Trainer Signature: